Alternative to tracheotomy in a newborn with CHARGE association

Patients with CHARGE (coloboma and cranial nerve abnormalities, heart malformation, choanal atresia, retardation of growth after birth and retardation of development, genital hypoplasia [underdevelopment] in males and urinary tract malformations, and ear malformations, deafness, or both) association are at high risk for swallowing and aspiration problems.' Pulmonary aspiration has been implicated as the most common cause of death in these patients.' In a recent review of CHARGE cases seen at Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, 20 of 30 patients have required a tracheostomy during the first year of life. This places a tremendous burden on caregivers and puts these patients at risk for tracheostomy-related complications. Because most patients are tube fed, the bulk of the aspirate comes from their salivary secretions. While botulinum toxin has been used in older children with sialorrhea, to our knowledge, it has never been tried in newborns to avoid a tracheostomy. The following case report illustrates the successful use of botulinum toxin type A (Botox; Allergan Inc, Irvine, California) injection in the salivary glands to avert the need for a tracheostomy in a newborn with CHARGE association.